General Assessment
This type of data includes patients report of nausea, vomiting and fever
Subjective data
the skin's primary protective outer layer
epidermis
This documentation term describes pupils that are equal, round, reactive to light, and reactive to accommodation. What is the term?
PERRLA
During a whispered voice test, the nurse stands at this distance from the client's unoccluded ear. What is the distance?
30-60cm
During a nose assessment, the nurse observes pale nasal mucosa and clear discharge. What do these findings most likely indicate?
Allergies
The four major techniques used in an objective health assessment
Inspection, Palpation, Percussion, Auscultation
a lesion that presents with widespread pinpoint, non-blanching, red-purple spots
petechiae
During a visual acuity challenge, a client reads the 20/40 line while standing 20 feet from the Snellen chart. What does the denominator indicate?
The distance at which a person with normal vision can read that line
The nurse observes a normal tympanic membrane during otoscopic examination. Which color describes a healthy tympanic membrane?
pearly-grey
The nurse asks a client to say “Ah” while inspecting the pharynx. Which finding indicates a normal response?
The uvula and soft palate rise centrally
The mnemonic PQRST is used to assess this
Pain and symptom severity/quality
the degree of a normal angle between the nail plate and proximal nail fold
160 degrees
During ophthalmoscopic examination, which finding is expected in a healthy optic disc?
a creamy yellow disc with distinct margins
During an otoscopic examination, the nurse is assessing a 4-year-old child. Which action correctly straightens the child’s external auditory canal?
pull auricle down and back
While inspecting a client’s oral cavity, the nurse notes a thick white patch on the buccal mucosa. Which interpretation is most appropriate?
The finding may represent leukoplakia and requires follow-up
A nurse should do this when an assessment reveals a life-threatening abnormality
initiate an immediate safety response and assess/support airway, breathing, and circulation as indicated
a bluish discoloration of the lips and nail beds
cyanosis
The nurse is assessing pupillary accommodation. Which instruction should the nurse give the client?
Look at a distant object and then focus on a test object held approximately 10 cm from the nose
The nurse notes that a client’s external auditory canal contains a yellow or green, foul-smelling discharge. What is the priority interpretation of this finding?
The finding may indicate infection or a foreign body
A client reports tenderness over the forehead and cheeks during a sinus assessment. Which technique should the nurse use to further assess the frontal sinuses?
Apply gentle upward pressure with the thumb over the eyebrow
the process of comparing assessment findings with expected findings to identify health problems
Clinical judgment or data interpretation
the nurse's priority when a patient has a irregular lesion with asymmetry, uneven border, color variation, and recent size change
arrange further follow up
While testing the pupillary light reflex, the nurse shines a penlight into the client’s left eye. The left pupil constricts, but the right pupil does not change. Which structure is most likely impaired?
The right oculomotor nerve
A client reports ear pain. The nurse finds that palpation of the tragus and gentle movement of the auricle increase the pain. Which condition is most consistent with this assessment finding?
External ear infection
The nurse asks a client to protrude the tongue during an oral assessment. Which finding indicates a possible abnormality of hypoglossal nerve function?
The tongue deviates to one side